Why Cogmed Matters for Traumatic Brain Injury – TBI. · Traumatic brain injury (TBI), also known as intracranial injury, occurs when an external force traumatically injures the

Why Cogmed Matters for Traumatic Brain Injury – TBI.

Presenter: Alison Winter [email protected] Tel: +44 (0) 7734 744 771 Facebook: CogmedUK Twitter: CogmedUK Customer Services: 0845 630 88 88 [email protected]

Contact Information:

mailto:[email protected]


Credit for notes and slides to:

Charles Shinaver, Ph.D Cognitive Consultant US [email protected]

Peter Entwistle, Ph.D Cognitive Consultant US [email protected]



Agenda

Why Working Memory, attention and executive functioning (EF) matter for TBI. WM & TBI: Survival, community integration, Quality of life, reduced

depression WM Correlates with EF

EF & TBI: Obtaining competitive employment, occupational outcomes, and social integration.

Cogmed Specific Studies & TBI Going back to Work:

Adults with TBI and vocational outcomes.

Going back to School:

Children with TBI and the effects upon learning.

1. Why does Working Memory,

attention and executive functioning

(EF) matter for TBI.

What is Traumatic Brain Injury [TBI]?

Key feature: TBI can cause a host of physical, cognitive, social, emotional, and

behavioral effects

Traumatic brain injury (TBI), also known as intracranial injury, occurs when an external force traumatically injures the brain. TBI can be classified based on severity, mechanism (closed or penetrating head injury), or other features (e.g., occurring in a specific location or over a widespread area).

Working memory is the ability to keep information

in your mind for a short period of time

(seconds)

and

be able to use this information in your

thinking

What is Working Memory [WM]?

Key feature: It has a limited capacity that varies greatly between individuals

Executive functions (also known as cognitive control and supervisory attentional system) is an umbrella term for the management (regulation, control) of cognitive processes, including: • Working memory • Reasoning • Task flexibility, • Problem solving • Planning and execution.

What is Executive Functioning [EF]?

Key feature: It is often affected by TBI even mild TBI can impair EF

TBI Long term effects & working memory (WM)

TBI can result in significant long-term negative effects on multiple aspects of life including employment.

• Reduced working memory along with age, injury, and lifestyle factors was associated with reduced long-term survival (Himanen, et al., 2011). – Age at injury and vocational outcome also correlated with reduced long-term survival (Himanen, et al., 2011). – Vocational outcome was associated with age, TBI severity, cognitive impairment, later TBI’s, and alcohol abuse (Himanen, et

al., 2011).

• Better Working Memory predicted “increased community integration, greater life satisfaction, and lower levels of depression. "

– General self-efficacy mediated the predictive value of working memory on life satisfaction and depression.” (Wood & Rutterford 2006). This was more than 10 years post TBI. In This study injury severity predicted only decreased life satisfaction.

– Demographic and cognitive factors may be more predictive of long- term outcomes than injury

severity. These authors emphasize the importance of early social intervention post TBI. (Wood & Rutterford, 2006).

Adult TBI, WM and EF correlate with Quality of Life (Dissertation, DaVanzo, 2009)

• 60 adult survivors of TBI.

• Administered Quality of Life after Brain Injury scale.

• “Results revealed moderate correlations between cognitive/linguistic impairment functions of short- term memory and working memory/executive function with QOL.”

• A strong correlation between participation and QOL.

Focal lesions in adults with acute mild TBI & neurocognitive outcome

(Lee, et al., 2008)

• Mild adult TBI patients had significantly worse performance on working memory tasks than matched controls at acute (<2 weeks), at 1 month and 1 year post injury.

• Also, CT and 3TMR imaging findings didn’t account for the cognitive impairment which may suggest that new techniques such as “diffusion tensor imaging” may be needed to provide biomarkers for Neurocognitive and functional outcome in mTBI.

Meta-Analytic Review of Neurocognitive Effects of Pediatric TBI

(Babikian and Asarnow, 2009)

28 publications reviewed from 1988-2007. 3 distinct injury severity levels, 3 time intervals for 14 key neurocognitive domains.

Time intervals:

Time 1: 0-5 months, Time 2: 6-23 months, Time 3: 24+ months.

Severity was based upon the Glasgow Coma Scale (GCS) score and often confirmed by clinical findings (such as loss of consciousness, posttraumatic amnesia, and/or positive neuroimaging findings).

Mild (GCS 13-15) Moderate (GCS 9-12) Severe (GCS 3-8)

We will only look at few items here.

Highlights: Intellectual deficits Pediatric TBI (Time 3=long-term > 24 + months) • Working Memory deficits Pediatric TBI

– ES (Effect size) Mild (.092), Moderate (.194), Severe (.453)

• Attention deficits Pediatric TBI (long-term 24 + months)

– ES Mild (< .347), Moderate (.316), Severe (.710)

• Processing speed deficits Pediatric TBI

– ES Mild (.336), Moderate (.731), Severe (.925)

Long term effects of Pediatric TBI with Intra Cranial Pressure (ICP) related to working memory, attention & executive functioning

(Slawik, et al., 2009)

• Study of Severe pediatric TBI patients:

– One group had ICP - intracranial pressure

– The other group did not.

– Both groups had normal IQ’s.

– ICP group only showed long-term deficits on “various measures of attention and executive function such as working memory, decision-making, and impulsivity.”

– This suggested ICP lead to “diffuse brain injury”

– Also, measures of attention and EF are sensitive to raised ICP.

TBI Severity & Impact on Working Memory (WM)

The more severe the injury the more severe the impact on WM. (Levin, et al., 2002; Roncadin, et al., 2004; Ewing-Cobbs et al., 2004; Conklin, et al., 2008).

TBI results in significantly lower VSWM & VWM (Gorman et al., 2012).

Severity of TBI predicts difficulty in producing speech sounds which is predicted by WM and pragmatic inference. (Dennis, et al., 2000)

• General Intellectual functioning/Global Cognitive functioning :

Post-injury relates to ability to return to work with less services – yet not receiving enough services might interfere with a successful transition for those that are more cognitively intact. (Ownsworth & McKenna, 2004; Perna, et al., 2012)

• Injury Severity Of TBI has been found to be a strong predictor of early TBI recovery (Wood & Rutherford, 2006).

• Premorbid functioning.

Other factors affecting TBI long term outcome

Family factors affecting Pediatric outcomes of TBI

• Parent psychological distress, perceived family burden, and coping skills affect outcomes (Yeates et al, 2002: J Ped Psych).

• Injury has long-term effects on academic and behavior outcomes but is moderated by family environment (Taylor et al, 2002: Neuropsychology).

• Parent acceptance of injury report lower stress than denial group, active coping increases when stressing the use of humor to decrease stress (Wade et la, 2001: J Clin Cons Psych).

Factors post TBI impacting return to work.

• Social perception abilities relate to interpersonal aspects of job functioning and social integration more generally.

– May need to train on reading social cues and situations. – Social outcomes associated with executive functioning, pragmatic language skills and social

problem-solving (Yeates et al, 2004: JINS). – Some authors suggest an early focus upon social intervention post TBI (Wood & Rutherford, 2006).

Addressing attention, memory, working memory and executive deficits can improve workplace outcomes.

• A significant proportion of TBI patients, including those who are severely injured, are able to return to productive employment if sufficient and appropriate effort is invested (Shames,Treger, Ring,& Giaquinto, 2007).

• Web-based family interventions after pediatric TBI have been found effective in helping families and improving outcomes (Wade et al, 2008: J head Trauma Rehab).

Cognitive Effects of Concussions – Mild TBI: Memory Problems

•Memory problems: This area has the most research supporting it. Many of these effects would be short-term.

•Working Memory (Terry, et al, 2012; Levin et al., 2002; Roncadin,

et al., 2004; Levin et al., 2004)

•Episodic Memory (Tremblay, et al, 2013; DeBeaumont, et al, 2009)

•Delayed memory (Killam, et al., 2005)

•Visual/verbal memory (Matser, et al, 2001; Covassin, et al., 2010)

•Immediate memory performance (Chapman, et al., 2006)

•Memory (Clark, 2010; Iverson, et al., 2004; Covassin et al, 2008)

One would expect that “returning to learn” might be a challenge after a concussion.

Distractible, forgetful students will find school difficult.

Students may struggle with response speed and need more time to complete work/tests.

Struggles getting started or completing tasks. Easily fatigued.

2. Cogmed Specific Studies & TBI

Population

Typical

ADHD/ Special needs

Brain Injury/Stroke

Cancer

Developmental/ Psychiatric Problems

Low WM and/or Academic

Achievement

Adults Children/ Adolescents Preschoolers

Thorell et al., 2008 * Bergman-Nutley et al., 2011

Söderqvist et al., 2011

* Klingberg et al., 2002,2005 * Holmes et al., 2010 * Gibson et al., 2010, 2013 * Mezzacappa et al., 2010 * Beck et al., 2010 Dahlin, 2011, 2013

* * Green et al., 2012 *Gray et al., 2012

*Egeland et al., 2013 * *Chacko et al., 2013

* Hovik et al.,2013 * Gropper et al., 2014

* * van Dongen-Boomsma et al., 2014

* * Hardy et al., 2012

* Kronenberger et al.,2010 * Løhaugen et al., 2011

* Roughan & Hadwin, 2011 * Bennett et al., 2013

* Holmes et al., 2009

* Homes & Gathercole, 2013 (Trial 2) * Dunning et al., 2013

Westerberg et al., 2007 * Lundqvist et al., 2010

* Johansson & Tornmalm, 2011 * Åkerlund et al., 2013 * Björkdahl et al., 2013

Klingberg et al., 2002 (exp. 2) Olesen et al., 2004

Westerberg & Klingberg, 2007 McNab et al., 2009

Brehmer et al., 2009; 2011; * 2012 Bellander et al., 2011

* Gibson et al., 2012, 2013 Söderqvist et al., 2013

* * Dunning & Holmes, 2014

46 Cogmed published studies cover range of ages & profiles

* Söderqvist et al., 2012 * Grunewaldt et al., 2013

* Holmes & Gathercole, 2013 (Trial 1)

* Saunders et al., 2014

Cogmed Slide Library 2014

Summary: Why Cogmed matters for Pediatric TBI & concussions (mild TBI)

• Pediatric TBI is often associated with academic difficulties – Decline in math skills and then recovery of math skills for children from less stressed families was

found (Taylor, et al., 2002). – Working Memory (WM) predicts Academic achievement. Cogmed improves WM.

• Outcomes often linked to family functioning – (Taylor, et al., 2002).

– Cogmed’s coaching structure supports efficient and effective functioning around improving working memory

• Low SES associated with worse outcomes (Taylor et al., 2002). – Cogmed’s impact is generally independent of SES

• Cognitive effects of pediatric TBI & Cogmed’s role: – –

Working memory: Executive functioning:

Directly addressed by Cogmed Arguably directly addressed by improving WM with

Cogmed given the strong correlation between the two. – Attention/concentration: Indirectly addressed by Cogmed – Memory: Indirectly addressed by Cogmed. Some data

on episodic memory here. – Processing speed: Impact unclear by Cogmed – Social Cognition: Impact unclear by Cogmed, some anecdotal data. – Inhibition Insufficient data for Cogmed

For Adults with TBI reduced WM has been associated with reduced survival.

WM has been associated with

community integration, better Quality of life & reduced depression.

WM Correlates with EF. Cogmed improves WM.

Better Executive Functioning in survivors of TBI has been found to be associated with obtaining competitive employment, better occupational outcomes, and social integration.

Summary: Why Cogmed matters for Adult TBI & concussions (mild TBI)

Cogmed Studies: Pilot study with stroke victims, Improvements in daily life after Cogmed

Westerberg et al., 2007

This study examined the impact of working memory training in 18 adult stroke victims who were randomly assigned to working memory training or a no treatment control condition.

Westerberg, H., Jacobaeus, H., Hirvikoski, T., Clevberger, P., Östensson, M.L., Bartfai, A., & Klingberg, T. (2007). Computerized working memory training after stroke – a pilot study. Brain Injury, 21(1), 21-29. doi: 10.1080/02699050601148726

Cogmed Slide Library l 2011

Cogmed with stroke survivors (Westerberg et al., 2007)

Population: Stroke survivors (1-3 years), ages 34 -65 years N

= 18 (n = 9 in each treatment and waitlist control groups)

Design: Randomized, Controlled, Test-retest

Inclusion criteria: stroke between 1-3 years ago, stroke documented by PET, MR or CT, age 30-65, daily PC access with internet at home, self-reported deficits in attention.

Exclusion criteria: IQ below 70, motor or perceptual handicap that prevents use of the program, changing Rx during study, Fulfilling criteria for Major depression, known history of abuse of alcohol or illicit drugs.

Treatment group showed statistically significant improvement over control on outcome measures:

1) Non trained visuo-spatial & verbal WM task (Span Board (ES = .83) & Digit Span; WAIS-RNI)

2) WM and Attention (PASAT & RUFF 2&7)

3) Decrease in cognitive symptoms (i.e.. memory problems and attention lapses) (CFQ)

No significant improvements on:

Non verbal reasoning task (Raven’s Standard Matrices), response inhibition task (Stroop), learning and declarative memory (Cleason Dahl)

Take Home: More than one year post stroke, Cogmed WM training can improve WM capacity and attention.


Cogmed with stroke survivors (Westerberg et al., 2007)


Cognitive Failures Questionnaire (CFQ)


(Broadbent, Cooper, FitzGerald & Parks, 1982) The following questions are about minor mistakes which everyone makes from time to time, but some of which happen more often than others. We want to know how often these things have happened to your in the past 6 months. Please circle the appropriate number. Very Quite often Occasion ally Very Never

often rarely 1. Do you read something and find you haven’t

been thinking about it and must read it again? 4 3 2 1 0

2. Do you find you forget why you went from one part of the house to the other?

4 3 2 1 0

3. Do you fail to notice signposts on the road? 4 3 2 1 0

4. Do you find you confuse right and left when giving directions?

4 3 2 1 0

5. Do you bump into people? 4 3 2 1 0

6. Do you find you forget whether you’ve turned off a light or a fire or locked the door?

4 3 2 1 0

7. Do you fail to listen to people’s names when you are meeting them?

4 3 2 1 0

8. Do you say something and realize afterwards that it might be taken as insulting?

4 3 2 1 0

9. Do you fail to hear people speaking to you when you are doing something else?

4 3 2 1 0

Summary (Westerberg et al., 2007)

“…The treatment group improved significantly more than the passive control group on the

nontrained tests that measured WM and attention…”

Training was found to yield significant improvement on non-trained measure of working memory and on attention

Participants reported significant improvement in their daily functioning

The study suggests a potential role of working memory training in the rehabilitation of stroke victims

Take Home: More than one year post stroke, Cogmed WM training can improve WM capacity and attention.


Cogmed helps heterogeneous group of brain injured adults reduce cognitive failure

(Lundqvist et al., 2010)

Lundqvist, A., Gundström, K., & Rönnberg, J.(2010). Computerized working memory training in a group of patients suffering from acquired brain injury. Brain Injury, 24(10), 1173- 1183.

Structured and intense working memory training improves subjects’ cognitive functioning, ratings of

occupational performance and ratings of overall health


WM training for acquired brain injury (Lundqvist et al., 2010)


Population: adults with acquired brain injury, ages 20 -65 years, heterogeneous, ~ 3 years post

N = 21 (n = 10 in treatment group and n = 11 in waitlist control), 10 men, 11 women. Mean age 43.2 years old. Time since injury onset 37 months. Trained with Cogmed QM.

Design: Randomized, Waitlist controlled, Test-retest

T1= baseline, T2 = 4 weeks post training, T3 = 5 month follow up

Treatment group evidenced significant improvements on outcome measures at T2 &T3:

1) WM and attention (PASAT)

2) Complex non-trained visuo-spatial and verbal tasks

(Block Span Board (ES = .71); WAIS R-NI, Listening Span, Picture Span(T3 only))

3) Verbal inhibition and executive shifting (CWIT; D-KEFS, Stroop)

4) Self reported occupational performance and satisfaction with performance (COPM)

(WM-related activities)

5) Overall health rating increased 20 weeks after training.

WM training for acquired brain injury (Lundqvist et al., 2010)

Take home: Heterogeneous group of brain injured adults self-report decreased cognitive failures and improved occupational performance and satisfaction. Interviews with and dairy entries of participants support questionnaire outcomes. Users with poorest baseline show most improvement.


Adults with ABI report improved occupational satisfaction after Cogmed training

(Johansson & Tornmalm, 2011)

Johansson, B., & Tornmalm, M. (2011). Working memory training for patients with acquired brain injury: Effects in daily life. Scandinavian Journal of Occupational Therapy. Advance online publication. doi: 10.3109/11038128.2011.603352

“Now I dare go for a walk, I think I can find my way back. Now I

know why I went from one room to another. I’m less stressed…It’s

easier to find things in my bag. It’s a small thing, but important for me…”


WM training for patients with acquired brain injury: Effects in daily life (Johansson & Tornmalm, 2011)

Population: N = 18 adults with ABI, ages 16-65 years (M=47.5 years), heterogeneous, 1-22 years post- event (M = 7 years)

Design: Test- retest, T1 = baseline, T2 = post-intervention, T3 = 6 month follow up Those with a lower baseline showed a greater percentage of improvement. In other words, those more impaired improved the most.

Baseline index correlates positively

with percent improvement


(Johansson & Tornmalm, 2011)

Results: Treatment group evidenced improvements at T2 and T3 on: (T1 = baseline, T2 = post-intervention, T3 = 6 month follow up)

1) Cognitive Failures Questionnaire (CFQ) – reduced cognitive problems

2) Canadian Occupational Performance Measure (COPM) (T2 data) – improved performance/satisfaction

3) Diary & Semi-structured interview – self awareness - // CQP & COPM


Take home: Heterogeneous group of brain injured adults self-report decreased cognitive failures and improved occupational performance and satisfaction. Interviews with and dairy entries of participants support questionnaire outcomes. Users with poorest baseline show most improvement.

WM training for patients with acquired brain injury: Effects in daily life

Can computerized working memory training improve impaired WM, cognition and psychological health?

(Akerlund, Esbjornsson, Sunerhagen, Bjorkdahl, 2013) Adults with acquired brain injury in the sub-acute phase after acquired brain injury average age= 47. 7

years, n = 47, range= 22-63. 3 stages of treatment for brain injury: Acute—to stabilize the patient immediately after the injury; Sub-acute—to rehabilitate and return the patient to the community; and Chronic—to continue rehabilitation and treat the long-term impairments. Design: Randomized included all outpatients at the Department of Rehabilitation Medicine, Sahlgrenska University Hospital, Goteborg, Sweden, during March 2008 to December 2010. BOTH GROUPS RECEIVED “rehabilitation in accordance with the normal routines at the clinic, based on their rehabilitation needs.” Patients included if below normal range on digits forward, digits reversed on WAIS-III; digit span and/or blocks forward and/or blocks reversed on the WAIS-III NI Span board. Exclusion criteria aphasia/non-Swedish communicable or if contra-indicated by MD (i.e. pronounced fatigue, pain or depression). Both groups were well-educated. IG: 3, 1-9 years ed., 8, 9-12 years ed, 14, 12+ years ed., CG 2, 1-9 years ed., 11, 9- 12 years ed, 7, 12+ years ed. No significant differences were found between the Intervention group (IG) and Control Group (CG) regarding gender, age, time since injury, RLS (reaction level scale), educational level, diagnosis

Can computerized working memory training improve impaired WM, cognition and psychological health?

(Akerlund, et al., 2013)

NOTE: For ethical reasons at the conclusion of the 18 weeks those in the CG who wanted to do Cogmed, did. Also, note similarly high levels of education among subjects. For this purpose the CG was divided into C1 and C2. C1 were those that did Cogmed. C2 were those that refused to do Cogmed.

(n=11) (n=10)

3. Returning to Work or School post

Moderate to Severe TBI

•Only 29.9% working full-time at time of interview compared to 64% pre-injury (Colantonio, Ratcliff, Chase et al., 2004). Longitudinal study 7 -24 years post TBI. •Return to competitive employment after severe brain injury is related to intellectual functioning both on initial exam (inpatient) and post-acute exam (discharged).

•Return to work: •Avg. VIQ (initial) 95 -108 (discharge) •PIQ (initial) 87-103 (discharge)

Not Return to work: •Avg. VIQ (initial) 78-88 (discharge) •PIQ initial 68-83 (discharge)

•Significant relationship between activity limits & Residual cognitive impairment at follow up.

•Biggest problem areas – shopping, managing money, and transportation – all correlate with EF.

Returning to Work after Moderate to Severe TBI

Going Back to School: Pediatric TBI’s Impact upon Learning

Children with TBI were disproportionately compromised in selective learning (SL) efficiency in contrast to memory span when compared to normally developing children.

Also, the effect of TBI on performance was demonstrated to take place at the time of encoding, rather than at retrieval(SL to learn items selected from among others)(Hanten, et al., 2002).

Encoding is know to be the time of skill acquisition and to place a larger load upon working memory (Huang-Pollock & Karalunas, 2010)

Language comprehension tasks with high working memory demands generally posed the most difficulty for adolescents with traumatic brain injury. (Moran & Gillon, 2004)

Pediatric TBI Impact upon Learning

Post TBI adolescents placed in High WM demand conditions performed poorly on understanding inferences, but not when WM demands were low. (Moran & Gillon, 2005). Moderate to severe TBI resulted in deficits in phonological loop (PL) and central executive tasks vs. controls in school-aged children. On new learning tasks the TBI group consistently produced fewer words. Results revealed impaired Phonological Loop function related to poor encoding and acquisition on a new verbal learning task in the TBI group. (Mandalis, et al., 2007)

Pediatric TBI’s Impact upon Learning Emerging evidence suggests that a traumatic brain injury (TBI) in childhood may disrupt the ability to abstract the central meaning or gist-based memory from connected language (Chapman, et al., 2006).

TBI groups showed decreased performance on a summary production task as well as retrieval of specific content from a long narrative (Chapman, et al., 2006).

WM on n-back tasks was impaired in children with severe TBI, whereas immediate memory performance for recall of a simple word list in both TBI groups was comparable to controls (Chapman, et al., 2006).

Interestingly, working memory, but not simple immediate memory for a word list, was significantly correlated with summarization ability and ability to recall discourse content. (Chapman, et al., 2006)

TBI Impact upon Learning

Adolescents with TBI differed from their non-injured peers in their understanding of proverbs. In addition, working memory capacity influenced performance for all participants. (Moran, et al., 2006) (5,499 in CA system).

Concerned about Learning Trajectories? Working Memory Predicts Achievement

Working Memory Components Most Highly Related to Types of Academic Learning

(Dehn, 2008) (Table 5.2 p. 95)

Reading Decoding

Reading Comprehension

Written Language

Math

Phonological STM

Executive WM Executive WM Visuospatial WM

Verbal WM Verbal WM Verbal WM Executive WM

Executive WM Phonological STM

NOTE: STM= Short-Term Memory

WM= Working Memory

What is Cogmed Working Memory TrainingTM?

1. Scientific – designed by leading neuroscientists

2. Adaptive – in real time

3. Intensive – hard work

4. Sustained – 25 sessions

5. Supported – your coach will be there

6. Targeted – wm only

Coaching Broadly Defined:

• Coaching:

• Behavioral.

• Specific.

•

•

•

Future-oriented toward behavioral change.

Emphases skill development. Removing of obstacles that prevent success (e.g. scheduling) Manages motivation…

Cogmed Coaching is Critical.

Working memory training acts on underlying levels

Reading comprehension

Math skills On-task behavior

Language development

Rate of learning

Manipulating information

Remembering Instructions

Concentration

Working memory

Planning Attention Task monitoring Organizing Executive function

Influences

Skill/behavior

Cogmed: Now on IPad.

Thank you, Any questions?

Presenter: Alison Winter [email protected] Tel: +44 (0) 7734 744 771 Facebook: CogmedUK Twitter: CogmedUK Customer Services: 0845 630 88 88 [email protected]

Contact Information:



Credit for notes and slides to:

Charles Shinaver, Ph.D Cognitive Consultant US [email protected]

Peter Entwistle, Ph.D Cognitive Consultant US [email protected]



Documents

Why Cogmed Matters for Traumatic Brain Injury – TBI. · Traumatic brain injury (TBI), also known as intracranial injury, occurs when an external force traumatically injures the